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D-OH-3502A V4 01/2012
Renaissance Ohio Group Dental Certificate
NOTICE: IF YOU OR YOUR FAMILY MEMBERS ARE COVERED BY MORE THAN
ONE HEALTH CARE PLAN, YOU MAY NOT BE ABLE TO COLLECT BENEFITS FROM
BOTH PLANS. EACH PLAN MAY REQUIRE YOU TO FOLLOW ITS RULES OR USE
SPECIFIC DOCTORS AND HOSPITALS, AND IT MAY BE IMPOSSIBLE TO COMPLY
WITH BOTH PLANS AT THE SAME TIME. READ ALL OF THE RULES VERY
CAREFULLY, INCLUDING THE COORDINATION OF BENEFITS SECTION, AND
COMPARE THEM WITH THE RULES OF ANY OTHER PLAN THAT COVERS YOUR OR
YOUR FAMILY.
P.O. Box 1596 Indianapolis, IN 46206 1-866-569-8654 www.RenaissanceDental.com
SAMPLE
D-OH-3502A V4 i. 01/2012
RENAISSANCE
OHIO GROUP DENTAL CERTIFICATE
Table of Contents
Summary of Dental Plan Benefits....................................................................................................1
I. Renaissance Group Dental Certificate ................................................................................3
II. Definitions............................................................................................................................3
III. General Eligibility Rules......................................................................................................5
IV. Benefits ................................................................................................................................6
V. Exclusions and Limitations ..................................................................................................9
VI. Accessing Your Benefits....................................................................................................10
VII. Questions and Answers ......................................................................................................11
VIII. Coordination of Benefits ....................................................................................................12
IX. Disputed Claims Procedure................................................................................................16
X. Termination of Coverage ...................................................................................................17
XI. Continuation of Coverage ..................................................................................................17
XII. General Conditions ............................................................................................................18
Important Cancellation Information – Please Read Section X Entitled, “Termination of Coverage”
THIS CERTIFICATE IS NOT A MEDICARE SUPPLEMENT CERTIFICATE. If you are
eligible for Medicare, review the Guide to Health Insurance for People with Medicare, which is
available from the company. Title II NCAC 12.0843 and Section 17.E.
NOTE: This Group Dental Certificate should be read in conjunction with the Summary of Dental
Plan Benefits that is provided with the Certificate. The Summary of Dental Plan Benefits lists the
specific provisions of your group dental plan. Your group dental plan is a legal contract between
the Policyholder and Renaissance Life & Health Insurance Company of America (“RLHICA”).
READ YOUR GROUP DENTAL CERTIFICATE CAREFULLY
SAMPLE
D-164A-OH V4.1 - 1 - 01/2012
Renaissance Life & Health Insurance Company of America Renaissance Group Dental Preferred Provider Certificate
Summary of Dental Plan Benefits For Group # 3305 – Max Choice PLUS Plan
World Travelers of America, Inc. This Summary of Dental Plan Benefits is part of, and should be read in conjunction with your Group Dental Certificate. Your Group Dental Certificate will provide you with additional information about your RENAISSANCE LIFE & HEALTH INSURANCE COMPANY OF AMERICA (“RLHICA”) coverage, including information about exclusions and limitations. Benefit Year is based on the member’s eligibility effective date Covered Services In-Network Out-of-Network RLHICA
Pays You Pay
RLHICA Pays You Pay
Diagnostic And Preventive Services 1st Year / 2nd Year / 3rd Year 1st Year / 2nd Year / 3rd Year Diagnostic and Preventive Services - Used to evaluate existing conditions and/or to prevent dental abnormalities or disease (includes exams and cleanings)
100% / 100% / 100% 0% / 0% / 0% 100% / 100% / 100% 0% / 0% / 0%
Brush Biopsy – Used to detect oral cancer 100% / 100% / 100% 0% / 0% / 0% 100% / 100% / 100% 0% / 0% / 0%
Basic Services
Fluoride Treatment- topical application of fluoride 40% / 60% / 80% 60% / 40% / 20% 40% / 60% / 80% 60% / 40% / 20%
Bitewing Radiographs- bitewing X-rays 40% / 60% / 80% 60% / 40% / 20% 40% / 60% / 80% 60% / 40% / 20%
Emergency Palliative Treatment - Used to temporarily relieve pain 40% / 60% / 80% 60% / 40% / 20% 40% / 60% / 80% 60% / 40% / 20%
Minor Restorative Services – Used to repair teeth damaged by disease or injury (for example, silver fillings and white fillings)
20% / 40% / 50% 80% / 60% / 50% 20% / 40% / 50% 80% / 60% / 50%
Sealants – Sealants for the occlusal surface of first and second permanent molars
40% / 60% / 80% 60% / 40% / 20% 40% / 60% / 80% 60% / 40% / 20%
Radiographs/Diagnostic Imaging/Diagnostic Casts - X-rays as required for routine care or as necessary for the diagnosis of a specific condition
20% / 40% / 50% 80% / 60% / 50% 20% / 40% / 50% 80% / 60% / 50%
Major Services
Simple Extractions – Simple extractions including local anesthesia, suturing, if needed and routine post-operative care
20% / 40% / 50% 80% / 60% / 50% 20% / 40% / 50% 80% / 60% / 50%
Space Maintenance – To prevent tooth movement 40% / 60% / 80% 60% / 40% / 20% 40% / 60% / 80% 60% / 40% / 20%
Periodontal Maintenance – Periodontal maintenance following active periodontal therapy
20% / 40% / 50% 80% / 60% / 50% 20% / 40% / 50% 80% / 60% / 50%
After-Hours Visits – Services performed by a dentist during after-hours visits
20% / 40% / 50% 80% / 60% / 50% 20% / 40% / 50% 80% / 60% / 50%
Oral Surgery Services – Extractions and dental surgery, including local anesthesia, suturing, if needed, and routine post-operative care
20% / 40% / 50% 80% / 60% / 50% 20% / 40% / 50% 80% / 60% / 50%
Endodontic Services – Used to treat teeth with diseased or damaged nerves (for example, root canals)
20% / 40% / 50% 80% / 60% / 50% 20% / 40% / 50% 80% / 60% / 50%
Periodontic Services – Used to treat diseases of the gums and supporting structures of the teeth
20% / 40% / 50% 80% / 60% / 50% 20% / 40% / 50% 80% / 60% / 50%
Major Restorative Services – Used when teeth can't be restored with another filling material (for example, crowns)
20% / 40% / 50% 80% / 60% / 50% 20% / 40% / 50% 80% / 60% / 50%
Prosthodontic Services – Used to replace missing natural teeth (for example, bridges, endosteal implants, partial dentures, and complete dentures)
20% / 40% / 50% 80% / 60% / 50% 20% / 40% / 50% 80% / 60% / 50%
Relines and Repairs – Relines and repairs to fixed bridges, partial dentures, and complete dentures
20% / 40% / 50% 80% / 60% / 50% 20% / 40% / 50% 80% / 60% / 50%
Other Major Services – Occlusal guards, and limited occlusal adjustments
20% / 40% / 50% 80% / 60% / 50% 20% / 40% / 50% 80% / 60% / 50%
Orthodontic Services
Orthodontic Services – Services , treatment, and procedures to correct malposed teeth (for example, braces) including Orthodontic Services for Children to the age of 19
10% / 25% / 50% 90% / 75% / 50% 10% / 25% / 50% 90% / 75% / 50%
SAMPLE
D-164A-OH V4.1 - 2 - 01/2012
Method of Payment – For services rendered or items provided by an In-Network Dentist, the Allowed Amount is a pre-negotiated fee that the provider has agreed to accept as payment in full. For services rendered or items provided by an Out-of-Network Dentist, RLHICA determines the Allowed Amount using statistically valid claims data submitted to RLHICA and its affiliates which show the most frequently charged fees by providers in the same geographic areas for comparable services or supplies. The claims data and fees are updated periodically using the most current codes and nomenclature developed and maintained by the American Dental Association. RLHICA will base Benefits on the lesser of the Submitted Amount and the Allowed Amount. If the Submitted Amount for an Out-of-Network Dentist is more than the Allowed Amount, you are not only responsible for paying the Dentist that percentage listed in the “You Pay” column, but are also responsible for paying the Dentist the difference between the Submitted Amount and the Allowed Amount.
Maximum Payment – $1,000 yr 1 / $2,000 yr 2 / $3,000 yr 3 per person per Benefit Year on Diagnostic and Preventive, Basic, and Major Services collectively.
$ 1,200 per person per lifetime on Orthodontic Services.
Deductible:
In-Network: $50 Deductible per person per Benefit Year limited to a maximum Deductible of $150 per family per Benefit Year on Basic and Major Services. The Deductible does not apply to Diagnostic and Preventive Services or Orthodontic Services.
Out-of-Network: $50 Deductible per person per Benefit Year limited to a maximum Deductible of $150 per family per Benefit Year. The Deductible does not apply to Orthodontic Services.
Waiting Period - All members (and their Eligible Dependents, if covered above) will be eligible for enrollment on the next available effective date.
Eligibility (Certificate Holder and Eligible Dependents) – All due-paying members in good standing and all individuals who are eligible for and elect Continuation Coverage pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1985 or similar applicable state law. (“COBRA”)
Where two Certificate Holders are eligible under the same group and are legally married to each other, they will be enrolled under one application and will receive Benefits under a single Certificate without coordination of benefits under the RLHICA Policy.
Also eligible are your Legal Spouse, your dependent unmarried Children who have not yet reached their 26th birthday, if the Child is dependent upon you for support.
The entire cost of coverage for a Certificate Holder and an Eligible Dependent(s) is paid by the Certificate Holder.
Benefits will cease on the last day of the month in which your coverage is terminated, subject to all applicable laws or regulations.
SAMPLE
D-OH-3502A V4 01/2012 3
PLEASE NOTE: RLHICA recommends
Predetermination before any services are rendered
where the total charges will exceed $200. You and
your Dentist should review your Predetermination
Notice before your Dentist proceeds with treatment.
I. Renaissance Group
Dental Certificate
RLHICA issues this Renaissance Group Dental Certificate
to you, the Certificate Holder. The Certificate is a
summary of your dental benefits coverage. It reflects and
is subject to the agreement between RLHICA and your
employer or organization (the “Policyholder”).
The Benefits provided under This Plan may change if
any state or federal laws change.
RLHICA agrees to provide Benefits as described in this
Certificate.
All the provisions in the following pages, read in
conjunction with the Summary of Dental Plan Benefits
and all attachments and addendums, form a part of this
document as fully as if they were stated over the
signature below.
IN WITNESS WHEREOF, this Certificate is
executed by an authorized officer of RLHICA.
Robert P. Mulligan
President and CEO
Home Office:
RENAISSANCE LIFE & HEALTH INSURANCE
COMPANY OF AMERICA
Attn: Renaissance Administration
P.O. Box 30381
Lansing, Michigan 48909-7881
Administrative Direct Line: 1-800-745-7509
Customer Service Direct Line: 1-866-569-8654
II. Definitions
Adverse Benefit Determination
Means any denial, reduction or termination of the
Benefits for which you filed a claim or a failure to
provide or to make payment (in whole or in part) of the
Benefits you sought, including any such determination
based on eligibility, application of any utilization review
criteria, or a determination that the item or service for
which Benefits are otherwise provided was experimental
or investigational, or was not medically necessary or
appropriate.
Allowed Amount
Means the maximum dollar amount upon which
RLHICA will base Benefits. RLHICA determines the
Allowed Amount using statistically valid claims data
submitted to RLHICA and its affiliates which show
the most frequently charged fees by providers in the
same geographic areas for comparable services or
supplies. The claims data and fees are updated
periodically using the most current codes and
nomenclature developed and maintained by the American
Dental Association. (This definition is only applicable if
the Allowed Amount method for Benefits is shown in the
Summary of Dental Plan Benefits Section).
Benefit Year
Means the calendar year, unless your employer or
organization elects the Policy Year to serve as the Benefit
Year. The Benefit Year is specified in the Summary of
Dental Plan Benefits Section.
Benefits
Means payment for Covered Services.
Certificate
Means this document. RLHICA will provide dental
Benefits as described in this Certificate. Any changes in
this Certificate will be based on changes to the Policy.
Changes to the Certificate will be in the Summary of
Dental Plan Benefits Section.
Certificate Holder
Means you, when your employer or organization certifies
to RLHICA that you are eligible to receive Benefits under
This Plan.
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D-OH-3502A V4 01/2012 4
Child(ren)
Means your natural children, stepchildren, adopted
children, foster children or children by virtue of legal
guardianship during the waiting period for legal
adoption or guardianship who are or meet one of the
following:
Your unmarried child(ren) who has not yet reached his or her 26th
birthday; or,
Your unmarried child(ren) who: (a) is under the
age of 26; (b) is a resident of the same state as the
you and is a full-time student; and (c) does not
have coverage, other than coverage as a
dependent, under another dental insurance Plan;
or, Your unmarried child(ren) or the child(ren) of
your Legal Spouse if, pursuant to a court decree
you or your Legal Spouse is financially
responsible for the dental care of the child; or
Your unmarried child(ren) who has reached the
end of the calendar year of his or her 26th birthday
and is both (a) incapable of self-sustaining
employment by reason of a mental or physical
condition and (b) chiefly dependent upon you for
support and maintenance. In the event that
RLHICA denies a claim for the reason that the
child has attained the Limiting Age for dependent
children, you have the burden of establishing that
the child continues to meet the two criteria
specified above. If requested by RLHICA, you
must submit medical reports confirming that the
child meets the two criteria specified above.
Coinsurance
Means the percentage of the Allowed Amount for
Covered Services that you will have to pay toward
treatment.
Completion Dates
Means the date that treatment is complete. Treatment is
complete:
for dentures and partial dentures, on the delivery
date;
for crowns and bridgework, on the permanent
cementation date;
for root canals and periodontal treatment, on the
date of the final procedure that completes
treatment.
Copayment
Means the dollar amount you must pay toward treatment.
Covered Services
Means the unique dental services selected for coverage by
your employer or organization under This Plan. The
Summary of Dental Plan Benefits Section lists your
Covered Services.
Deductible
Means the amount an individual and/or a family must pay
toward Covered Services before RLHICA begins paying
for those services. The Summary of Dental Plan Benefits
Section lists the Deductible that applies to you, if any.
Dentist
Means a person licensed to practice dentistry in the state
or jurisdiction in which dental services are rendered.
Eligible Dependent
Means (a) your Legal Spouse; (b) your Child(ren); and
(c) any other dependents who meet the criteria for
eligibility set forth in the Summary of Dental Plan
Benefits Section. If dependent coverage has been
selected, it will be indicated in the Summary of Dental
Plan Benefits Section.
Legal Spouse
Means a person who is any of the following: (a) your
spouse through a marriage legally recognized by the State in
which the Policy was issued; (b) your partner through a civil
union legally recognized by the State in which the Policy
was issued.
Limiting Age
Means the age at which a Child of yours is no longer
eligible for Benefits under This Plan pursuant to the
definition of Child above.
Maximum Payment
Means the maximum dollar amount RLHICA will pay in
any Benefit Year or lifetime for Covered Services. (See
the Summary of Dental Plan Benefits Section.)
SAMPLE
D-OH-3502A V4 01/2012 5
Open Enrollment Period
Means the period of time during which an eligible person
as indicated in the Summary of Dental Plan Benefits
Section may enroll or be enrolled to receive Benefits.
Policy
Means the insurance contract for the provision of
Benefits to you and your Eligible Dependents between
RLHICA and your employer or organization.
Policy Year
Means the 12 month period beginning on the first
Effective Date of the Policy and each 12 month renewal
period thereafter.
Predetermination
Means a voluntary and optional process where, at the
request of you, your Eligible Dependent or Dentist,
RLHICA issues a written estimate of dental benefits
which may be available for a proposed dental service
under the terms of your coverage.
Predetermination is provided for informational
purposes only and is not required in advance of
obtaining dental care or as a prerequisite or condition
for approval of future dental benefits payment. The
benefits estimate provided on a Predetermination notice
is determined based on the benefits available for you or
your Eligible Dependent on the date the notice is
issued, and is not a guarantee of future dental benefits
payment.
Availability of dental benefits at the time a dental
service is completed depends on factors such as, but not
limited to, eligibility for Benefits, annual or lifetime
Maximum Payments, coordination of benefits, Policy
and Dentist status, Policy limitations and other
provisions. A request for a Predetermination is not a
claim for Benefits or a preauthorization, precertification
or other reservation of future Benefits.
RLHICA
Means Renaissance Life & Health Insurance Company
of America.
Submitted Amount
Means the fee a Dentist bills to RLHICA for a specific
service or item.
Summary of Dental Plan Benefits
Means a list of the specific provisions of This Plan and
is a part of this Certificate.
Table of Allowances
Means the maximum amount allowed per procedure as
determined by your employer or organization and
RLHICA. (If the Table of Allowances method for
Benefits has been selected by your employer or
organization, it will be reflected in the Summary of
Dental Plan Benefits Section).
This Plan
Means the dental coverage as provided for you and your
Eligible Dependents pursuant to this Certificate.
III. General Eligibility Rules
A. You are not eligible for Benefits unless you are either
currently enrolled in This Plan or currently listed as
an Eligible Dependent.
B. Effective Date of Eligibility
1. Initial Effective Date: All Certificate Holders
and Eligible Dependents on the Effective Date of
the Policy are immediately eligible for Benefits.
2. After the initial Effective Date: For all Certificate
Holders (and their Eligible Dependents) not
associated with the employer or organization on the
initial Effective Date of the Policy, eligibility for
Benefits will begin, unless otherwise stated as
follows:
a. Newly hired or rehired employees: Date for
which employment compensation begins. Or,
if applicable, that date plus the number of
days specified as a waiting period in the
Summary of Dental Plan Benefits Section;
b. Spouse: Date of marriage, civil union or
domestic partnership;
c. Newborn: Child's actual date of birth;
d. Foster children, legal adoptions or
guardianships: Date the Child is placed in
the foster home or with the Certificate
Holder; at which time this Child will be
covered on the same basis as a natural child;
e. Stepchild: Date that the Child’s natural parent
becomes an Eligible Dependent;
f. All others: Date that RLHICA approves in
writing the enrollment or listing of those
people, unless compelled by a court or
administrative order to otherwise provide
Benefits for a Child or Eligible Dependent.
Once eligible, you and your Eligible Dependents
must enroll for coverage within 31 days from the
SAMPLE
D-OH-3502A V4 01/2012 6
date upon which you or your Eligible Dependents
become eligible for Benefits under the terms of
Section III B immediately above. You and your
Eligible Dependents may properly enroll for
coverage by completing all enrollment forms
required by RLHICA and submitting such forms
to your employer or organization. If you and your
Eligible Dependents are not properly enrolled for
coverage within 31 days from the date upon
which you and your Eligible Dependents become
eligible for Benefits, then you and/or your
Eligible Dependents must wait until the next
Open Enrollment Period to enroll.
C. Termination of Eligibility
Eligibility for Benefits will terminate for you and
your Eligible Dependents under This Plan at the
earlier of:
1. The termination of the Policy; or
2. The last day of the month for which payment
has been made if the employer or organization
fails to make the payments required by their
Policy.
Your eligibility, and that of your Eligible
Dependents, will also terminate if you cease to be a
Certificate Holder as defined in the Summary of
Dental Plan Benefits Section. An Eligible
Dependent’s eligibility also terminates upon lack of
compliance with the eligibility requirements of the
Policy.
D. Conversion to an Individual Policy
A person whose eligibility is terminated or who
loses coverage may be eligible to apply for an
individual direct payment policy with RLHICA.
Any request to obtain such a policy will be subject
to applicable state law. Please contact RLHICA to
obtain further information.
IV. Benefits
COVERED SERVICES
RLHICA agrees to provide Benefits to you and your
Eligible Dependents under the policies and procedures
of RLHICA and under the terms and conditions of This
Plan, including, but not limited to, the categories of
services, exclusions and limitations listed below.
Unless otherwise specified in the Summary of Dental
Plan Benefits Section, Covered Services may be
divided into the following categories and are subject to
the exclusions and limitations listed below. Please see
the Summary of Dental Plan Benefits Section for the
Benefits, exclusions and limitations applicable under
This Plan.
A detailed list of the Benefits provided under This Plan is
available upon request. All time limitations are measured
either from the last date of service in any RLHICA plan
or, at the request of your employer or organization, from
the last date of service in any dental Plan.
DIAGNOSTIC AND PREVENTIVE SERVICES
Services and procedures to evaluate existing conditions
and/or to prevent dental abnormalities or disease. These
services include oral evaluations (examinations),
prophylaxes (cleanings), bitewing X-rays and fluoride
treatments. These services are subject to the following
exclusions and limitations:
(i) Topical fluoride treatments are payable once in any
Benefit Year for Children under age 16;
(ii) Oral examinations submitted as a consultation or
evaluation are payable twice in any Benefit Year,
whether provided under one or more RLHICA
Plans;
(iii) Prophylaxes, including periodontal maintenance
procedures, are payable three times in any Benefit
Year;
(iv) Bitewing X-rays are payable once in any Benefit
Year;
(v) Space maintenance services are payable once per
lifetime, per area on posterior teeth, for Children
under age 16;
(vi) RLHICA will not make payment for preventive
control programs, including home care items, oral
hygiene instructions, nutritional counseling and
tobacco counseling and all charges for the same
will be your responsibility;
(vii) RLHICA will not make payment for tests and
laboratory examinations (including, but not limited
to cytology, bacteriology or pathology) and caries
susceptibility tests and all charges for the same will
be your responsibility, unless otherwise indicated in
the Summary of Dental Plan Benefits Section or in
this Certificate.
Brush Biopsy
Oral brush biopsy procedure and laboratory analysis used
to detect oral cancer, an important tool that identifies and
analyzes precancerous and cancerous cells.
SAMPLE
D-OH-3502A V4 01/2012 7
BASIC SERVICES
Emergency Palliative Treatment
Emergency treatment to temporarily relieve pain is not
a Covered Service when done in conjunction with any
services except X-rays, tests or examinations.
Radiographs (X-rays)/Diagnostic
Imaging/Diagnostic Casts
X-rays as required for routine care or as necessary for
the diagnosis of a specific condition, subject to the
following exclusions and limitations:
(i) Full mouth X-rays (which include bitewing X-
rays) or a panoramic X-ray (with or without
bitewing X-rays) are payable once in any 3 year
period;
(ii) A serial listing of X-rays is paid as a full mouth
series if the total fee equals or exceeds the fee for
a complete series;
(iii) Any supplemental films with a full mouth series
are part of the complete procedure;
(iv) Cephalometric films, oral/facial images or
diagnostic casts are not payable except in
conjunction with Orthodontic Services and all
charges for the same will be your responsibility;
(v) Posterior-anterior or lateral skull and facial bone
survey, sialography, temporomandibular joint
films (including arthrograms) or tomographic
films are not payable and all charges for the same
will be your responsibility.
Minor Restorative Services
Minor restorative services to rebuild and repair natural
tooth structure when damaged by disease or injury.
These services include amalgam (silver) and composite
resin (white) restorations (fillings), subject to the
following exclusions and limitations:
(i) Amalgam and composite resin restorations are
payable once per tooth surface within a 24 month
period regardless of the number or combination of
restorations placed on a surface;
(ii) RLHICA will not make payment for dentistry for
aesthetic reasons and all charges for the same will
be your responsibility.
Simple Extractions
Simple extractions including local anesthesia, suturing,
if needed, and routine post-operative care.
Sealants
Sealants are payable only for the occlusal surface of first
permanent molars for Children under age 16 and second
permanent molars for Children under age 16. The surface
must be free from decay and restorations. Sealants are a
Benefit payable once in any 3 year period.
Periodontal Maintenance Following Therapy
Periodontal maintenance following active periodontal
therapy procedures to treat diseases of the gums and
supportive structures of the teeth, along with benefits for
prophylaxes, including periodontal maintenance
procedures, are payable three times in any Benefit Year.
Other Basic Services
After hours visits, not to exceed once per Benefit Year.
MAJOR SERVICES
Oral Surgery Services
Surgical extractions and dental surgery, including local
anesthesia, suturing, if needed, and routine postoperative
care are subject to the following exclusions and
limitations:
(i) RLHICA will not make payment for the following
services and items and all charges for the same will be
your responsibility unless otherwise specified in the
Summary of Dental Plan Benefits Section: appliances,
restorations, X-rays or other services for the diagnosis
or treatment of temporomandibular disorders
(“TMD”) including myofunctional therapy;
(ii) RLHICA will not make payment for the following
services and items and all charges for the same will
be your responsibility: charges related to
hospitalization or general anesthesia and/or
intravenous sedation for restorative dentistry or
surgical procedure unless a specified need is shown.
Endodontic Services
The treatment of teeth with diseased or damaged nerves
(for example, root canals) is subject to the following
exclusions and limitations:
(i) Endodontic therapy, endodontic retreatment, and
apicoectomy/periradicular services are payable
once per tooth in any 24 month period;
(ii) Root canal fillings on primary teeth are limited to
primary teeth without succedaneous (replacement)
teeth;
(iii) RLHICA will not make payment for pulp caps and
all charges for the same will be your responsibility.
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D-OH-3502A V4 01/2012 8
Maxillofacial Prosthetics
RLHICA will not make payment for maxillofacial
prosthetics and all charges for the same will be your
responsibility.
Periodontic Services
The treatment of diseases of the gums and supporting
structures of the teeth is subject to the following
exclusions and limitations:
(i) Full mouth debridement will be payable once in
your or your Eligible Dependent’s lifetime;
(ii) Scaling and root planing are payable once per area
in any 24 month period;
(iii) Periodontal surgery is payable once per area in
any 3 year period.
Major Restorative Services
Major restorative services, such as crowns, used when
teeth cannot be restored with another filling material.
These services are subject to the following exclusions
and limitations:
(i) Indirect restorations including porcelain/ceramic
substrate, porcelain/resin processed to metal and
cast restorations (including crowns and onlays)
and associated procedures such as cores and post
and core substructures on the same tooth are
payable once in any 5 year period;
(ii) Substructures and indirect restorations, including
porcelain/ceramic substrate, porcelain/resin
processed to metal and cast restorations are not
payable for Children under age 12 and all charges
for the same will be your responsibility;
(iii) Optional treatment: if you or your Eligible
Dependent selects a more expensive service than
is customarily provided or for which RLHICA
does not determine that a valid dental need is
shown, RLHICA may make an allowance based
on the fee for the customarily provided service.
You are responsible for the difference in cost;
(iv) Inlays, regardless of the material used: RLHICA
will pay only the applicable amount that it would
have paid for a resin-based composite restoration.
You will be responsible for any additional
charges;
(v) RLHICA will not make payment for the
following services and items and all charges for
the same will be the responsibility of the
Certificate Holder: charges related to
hospitalization or general anesthesia and/or
intravenous sedation for restorative dentistry or
surgical procedure unless a specified need is
shown;
(vi) RLHICA will not make payment for dentistry for
aesthetic reasons and all charges for the same will
be your responsibility;
(vii) Veneers are not a Covered Service and all charges
for the same will be your responsibility.
Prosthodontic Services
Services and appliances that replace missing natural teeth
(such as fixed bridges, endosteal implants, partial
dentures and complete dentures) are subject to the
following exclusions and limitations:
(i) One complete upper and one complete lower
denture is payable once in any 5 year period for
any individual;
(ii) A partial denture, fixed bridge and any associated
services are payable once in any 5 year period;
(iii) Fixed bridges, endosteal implants and cast metal
partial dentures are not payable for Children under
age 16 and all charges for the same will be your
responsibility;
(iv) Optional treatment: if you or your Eligible
Dependent selects a more expensive service than is
customarily provided or for which RLHICA does not
determine that a valid dental need is shown, RLHICA
may make an allowance based on the fee for the
customarily provided service. You are responsible for
the difference in cost;
(v) Services for tissue conditioning are payable twice
per denture unit in any 3 year period;
(vi) Endosteal implants are allowed once per tooth, per
lifetime. RLHICA will not make payment if the
implant is placed within 5 years following
prosthodontic or major restorative services
involving that tooth and all charges for the same
will be your responsibility;
(vii) RLHICA will not make payment for specialized
implant surgical techniques, removal of an implant,
implant maintenance procedures or implant repairs
and all charges for the same will be your
responsibility unless otherwise specified in the
Summary of Dental Plan Benefits Section;
(viii) RLHICA will not make payment for the following
services and items and all charges for the same will
be your responsibility: lost, missing or stolen
appliances of any type; temporary, provisional or
interim prosthodontic appliances; precision or semi-
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precision attachments, copings or myofunctional
therapy;
Relines and Repairs
Relines and repairs to fixed bridges, partial dentures and
complete dentures. A reline or a complete replacement
of denture base material is limited to once in any 3 year
period per appliance.
Other Major Services
(i) An occlusal guard is payable once in your or your
Eligible Dependent’s lifetime;
(ii) Limited occlusal adjustments are limited to 1 in a
5 year period;
(iii) RLHICA will not make payment for the
following services and items and all charges for
the same will be your responsibility: repair,
relines or adjustments of occlusal guards.
ORTHODONTIC SERVICES
No person will be eligible for Orthodontic Services
under the Policy unless Orthodontic Services are
provided for in the Summary of Dental Plan Benefits
Section. Services, treatment and procedures to correct
malposed teeth (for example, braces), are subject to the
following exclusions and limitations:
(i) RLHICA's payment for Orthodontic Services
will be limited to the lifetime Maximum Payment
specified in the Summary of Dental Plan Benefits
Section;
(ii) Orthodontic Services are payable until the end of
the calendar year of the 19th birthday of you or
your Eligible Dependent unless otherwise
specified in the Summary of Dental Plan Benefits
Section;
(iii) RLHICA’s payment for Orthodontic Retention
Services (removal of appliances, construction and
placement of retainer) is included in its payment
of overall Orthodontic Services. If a Dentist bills
these services separately, payment will be denied.
(iv) If the treatment plan is terminated before
completion of the case for any reason, RLHICA’s
obligation will cease with payment up to the date
of termination;
(v) The Dentist may terminate treatment, with written
notification to RLHICA and to the patient, for lack
of patient interest and cooperation. In those cases,
RLHICA’s obligation for payment ends on the last
day of the month in which the patient was last
treated;
(vi) RLHICA will not make payment for the following
services and items and all charges for the same will
be your responsibility: lost, missing, or stolen
appliances of any type or replacement or repair of
an orthodontic appliance.
Other Services
The Summary of Dental Plan Benefits Section lists any
other Benefits that may have been selected.
V. Exclusions and
Limitations
Exclusions
In addition to the exclusions listed above in the Benefits
Section, RLHICA will not make payment for the
following services, items or supplies and all charges for
the same will be your responsibility, unless otherwise
specified in the Summary of Dental Plan Benefits
Section:
1. Services for injuries or conditions paid pursuant to
Workers’ Compensation or Employer’s Liability
laws. Services that are received from any
government agency, political subdivision,
community agency, foundation or similar entity.
NOTE: This provision does not apply to any
programs provided under Title XIX of the Social
Security Act, that is, Medicaid;
2. Services or appliances started prior to the date the
person became eligible under This Plan, excluding
orthodontic treatment in progress (if a Covered
Service);
3. Charges for failure to keep a scheduled visit with the
Dentist;
4. Charges for completion of forms or submission of
claims;
5. Services, items or supplies for which no valid dental
need can be demonstrated, as determined by RLHICA;
6. Services, items or supplies that are specialized
techniques, as determined by RLHICA;
7. Services, items or supplies that are investigational in
nature, including services, items or supplies required to
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treat complications from investigational procedures,
as determined by RLHICA;
8. Treatment by other than a Dentist, except for
services performed by a licensed dental hygienist or
other licensed provider under the scope of his or her
license or other licensed provider;
9. Services, items or supplies excluded by the policies
and procedures of RLHICA;
10. Services, items or supplies which are not rendered
in accordance with accepted standards of dental
practice, as determined by RLHICA;
11. Services, items or supplies for which no charge is
made, for which the patient is not legally obligated
to pay or for which no charge would be made in
the absence of RLHICA coverage;
12. Services, items or supplies received as a result of
dental disease, defect, or injury due to an act of
war, declared or undeclared;
13. Services, items or supplies that are generally
covered under a hospital, surgical/medical or
prescription drug program;
14. Services, items or supplies that are not within the
categories of Benefits that have been selected by
your employer or organization and are not covered
in This Plan;
15. Prescription drugs, non-prescription drugs,
premedications, localized delivery of
chemotherapeutic agents, relative analgesia, non-
intravenous conscious sedation, therapeutic drug
injections, hospital visits, desensitizing
medicaments and techniques, behavior
management, athletic mouthguards,
house/extended care facility visits, mounted
occlusal analysis, complete occlusal adjustments,
enamel microabrasions, odontoplasty or bleaching;
16. Correction of congenital or developmental
malformations, cosmetic surgery or dentistry for
aesthetic reasons as determined by RLHICA;
17. Any appliance or surgical procedure used to: (a)
change vertical dimension; (b) restore or maintain
occlusion; (c) replace tooth structure lost as a
result of abrasion, attrition, abfraction or erosion;
or (d) splint or stabilize teeth for periodontal
reasons.
Limitations
In addition to the limitations listed above in the
Benefits Section, the following limitations apply under
This Plan, unless otherwise specified in the Summary of
Dental Plan Benefits Section:
1. RLHICA’s obligation for payment of Benefits ends
on the last day of the month in which coverage is
terminated under This Plan;
2. When services in progress are interrupted and
completed later by another Dentist, RLHICA will
review the claim to determine the amount of
payment, if any, to each Dentist;
3. Care terminated due to the death of a Certificate
Holder or Eligible Dependent will be paid to the
limit of RLHICA’s liability for the services
completed or in progress;
4. The Maximum Payment will be limited to the
amount specified in the Summary of Dental Plan
Benefits Section;
5. If a Deductible amount is specified in the Summary
of Dental Plan Benefits Section, RLHICA will not
be obligated to pay, in whole or in part, for any
services, items or supplies to which the Deductible
applies, until the Deductible amount is met.
VI. Accessing Your Benefits
To access your Benefits, follow these steps:
1. Please read this Certificate, including the Summary of
Dental Plan Benefits Section carefully to become
familiar with the Benefits and provisions of This
Plan;
2. Make an appointment with your Dentist and tell him
or her that you have coverage with RLHICA. If the
dental office needs a claim form, you may obtain
one from your employer, organization, or plan
administrator. If your Dentist is not familiar with
This Plan or has any questions regarding This Plan,
have him or her contact RLHICA by writing
Attention: Customer Services Department, P.O. Box
1596, Indianapolis, IN 46206-1596 or by calling the
toll-free number, 1-866-569-8654;
3. After receiving your dental treatment, you or the
dental office staff will file a claim form, completing
the information portion with:
a. Your full name and address;
b. Your Social Security number;
c. The name and date of birth of the person
receiving dental care; and
d. The group’s name and number.
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Upon request, RLHICA will furnish to you, the
claimant, such forms as are usually furnished by it for
filing proofs of loss. If such forms are not furnished
within 15 days after such request, you will be deemed
to have complied with the requirements of This Plan as
to proof of loss upon submitting, within the time frame
for filing proofs of loss as described below, written
proof covering the occurrence, the character and the
extent of the loss for which claim is made.
Written proof of loss must be given within 90 days after
such loss. If it was not reasonably possible to give
written proof in the time required, RLHICA shall not
reduce or deny the claim for this reason if the proof is
filed as soon as reasonably possible. In any event, the
proof required must be given no later than one (1) year
from the time specified unless the claimant was legally
incapacitated.
Claims, adjustment requests, and completed
information requests should be mailed to:
RLHICA
P.O. Box 17250
Indianapolis, IN 46217
After receiving all required claim information,
RLHICA will pay all Benefits due for Covered Services
as soon as received and within 30 days. If applicable,
failure to pay within that period shall entitle you to
interest at the state prescribed rate per annum from the
30th day. Interest amounts less than one dollar ($1.00)
will not be paid.
Payment for services rendered is sent to either (1) you,
and it is your responsibility to make full payment to the
Dentist; or (2) directly to the Dentist if you or your
Eligible Dependent have assigned Benefits to the
Dentist who rendered Covered Services under This
Plan.
Upon the payment of a claim under This Plan, any
premium then due and unpaid or covered by any note or
written order may be deducted therefrom.
If you file a claim for a Benefit that relates to a service that
has already been rendered, and you receive notice of an
Adverse Benefit Determination, RLHICA will notify you
or your authorized representative of the Adverse Benefit
Determination within a reasonable period of time, but not
later than 30 days after receipt of the claim. RLHICA
may extend this period by up to 15 days if RLHICA
determines that the extension is necessary due to matters
out of RLHICA's control.
If RLHICA determines that an extension is necessary, it
will notify you before the end of the original 30 day
period of the circumstances requiring the extension and
the date by which RLHICA expects to render a
decision. If such an extension is necessary because you
did not submit all the information necessary to decide the
claim, the notice of extension will specifically describe
the additional information required. You will have at
least 45 days to provide the requested information. If you
deliver the information within the time specified, the 15
day extension period will begin after you provide the
information.
Note: RLHICA recommends Predetermination before any
services are rendered where the total charges will exceed
$200. You and your Dentist should review your
Predetermination Notice before your Dentist proceeds
with treatment.
If you have any questions about This Plan, please check
with your employer, organization, or plan administrator
or you may call RLHICA’s Customer Services
Department toll-free at 1-866-569-8654. You may also
write to RLHICA’s Customer Services Department, P.O.
Box 1596, Indianapolis, IN 46206-1596. When writing to
RLHICA please include your name, the group’s name and
number, the Certificate Holder’s Social Security number,
and your daytime telephone number.
VII. Questions and Answers
May I choose any Dentist?
Yes, you are free to choose any Dentist, as long as the
Dentist is licensed to practice dentistry in the state or
jurisdiction in which you receive care.
Will RLHICA send payment to the Dentist or will I
receive payment?
RLHICA will either send payment to you or directly to
the Dentist if you have assigned Benefit payments to the
Dentist who rendered Covered Services.
When does my dental coverage begin?
See Waiting Period in the Summary of Dental Plan
Benefits Section. This Plan will cover only those dental
services received after you become eligible.
How much of the dental bill do I pay?
It depends on whether your employer or organization
selected the Allowed Amount or the Table of Allowances
payment method. If the "Allowed Amount" payment
method has been selected, RLHICA will pay a certain
percentage of the amount for each Covered Service,
depending on the type of service rendered. Those Allowed
Amounts are listed in the Summary of Dental Plan Benefits
Section. If the Submitted Amount is more than the Allowed
Amount for a specific Covered Service, then you are
responsible for paying the Dentist that percentage listed in
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D-OH-3502A V4 01/2012
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the “You Pay” column, as well as for paying the Dentist
the difference between the Submitted Amount and the
Allowed Amount. On the other hand, if your employer or
organization selected the "Table of Allowances" payment
method, RLHICA will only pay up to a specific dollar
amount that is listed for each Covered Service in the Table
of Allowances, which is listed in the Summary of Dental
Plan Benefits Section.
In either case, you are responsible for the Copayment
shown on your explanation of benefits plus any charges
for optional treatment or specific exclusions /
limitations of This Plan.
Am I covered for all dental services?
No, the Summary of Dental Plan Benefits Section
describes the dental services that are covered by This
Plan. Please read them carefully. The exclusions and
limitations govern these covered dental services.
What if my spouse is covered by another plan?
If you are covered by more than one dental Plan, your
out-of-pocket costs may be reduced or eliminated.
Please see Section VIII Coordination of Benefits. It is
important to tell your Dentist about any other dental
coverage so that claims are submitted properly.
VIII. Coordination of
Benefits
COORDINATION OF THE GROUP CONTRACTS
BENEFITS WITH OTHER BENEFITS
All of the Benefits under this Certificate, if applicable,
will be subject to a Coordination of Benefits (“COB”)
provision that is designed to provide maximum
coverage, but not result in payment of more than 100
percent of the total fee for a given treatment.
A. APPLICABILITY
1. This COB provision applies to This Plan when
you or your Eligible Dependent has health care
coverage under more than one Plan. “Plan” and
“This Plan” are defined below.
2. The order of benefit determination rules govern
the order in which each Plan will pay a claim
for benefits. The Plan that pays first is called
the Primary Plan. The Primary plan must pay
benefits in accordance with its policy terms
without regard to the possibility that another
Plan may cover some expenses. The Plan that
pays after the Primary plan is the Secondary
Plan. The Secondary Plan may reduce the
benefits it pays so that payments from all Plans
do not exceed 100% of the total Allowable
expense.
B. DEFINITIONS
1. Plan is any of the following that provides
benefits or services for medical or dental care or
treatment. If separate contracts are used to
provide coordinated coverage for members of a
group, the separate contracts are considered parts
of the same Plan and there is no COB among
those separate contracts.
a. Plan includes: group and non-group
insurance contracts, health insuring
corporation ("HIC") contracts, closed panel
Plans or other forms of group or group-type
coverage (whether insured or uninsured);
medical care components of long-term care
contracts, such as skilled nursing care;
medical benefits under group or individual
automobile contracts; and Medicare or any
other federal governmental Plan, as permitted
by law.
b. Plan does not include: hospital indemnity
coverage or other fixed indemnity coverage;
accident only coverage; specified disease or
specified accident coverage; supplemental
coverage as described in Revised Code
sections 3923.37 and 1751.56; school
accident type coverage; benefits for non-
medical components of long-term care
policies; Medicare supplement policies;
Medicaid policies; or coverage under other
federal governmental Plans, unless permitted
by law.
Each contract for coverage under (a) or (b) is
a separate Plan. If a Plan has two parts and
COB rules apply only to one of the two, each
of the parts is treated as a separate Plan.
c. This Plan means, in a COB provision, the
part of the contract providing the health care
benefits to which the COB provision applies
and which may be reduced because of the
benefits of other Plans. Any other part of the
contract providing health care benefits is
separate from this Plan. A contract may
apply one COB provision to certain benefits,
such as dental benefits, coordinating only
with similar benefits, and may apply another
COB provision to coordinate other benefits.
d. The order of benefit determination rules
determine whether this Plan is a Primary Plan
or Secondary Plan when the person has
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D-OH-3502A V4 01/2012
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health care coverage under more than one
Plan.
When this Plan is primary, it determines
payment for its benefits first before those of
any other Plan without considering any other
Plan's benefits. When this Plan is secondary, it
determines its benefits after those of another
Plan and may reduce the benefits it pays so that
all Plan benefits do not exceed 100% of the
total Allowable expense.
2. Allowable Expense is a health care expense,
including deductibles, coinsurance and
copayments, that is covered at least in part by
any Plan covering the person. When a Plan
provides payment for services, the reasonable
cash value of each service will be considered an
Allowable expense and a benefit paid. An
expense that is not covered by any Plan
covering the person is not an Allowable
expense. In addition, any expense that a
provider by law or in accordance with a
contractual agreement is prohibited from
charging a covered person is not an Allowable
expense.
The following are examples of expenses that
are not Allowable Expenses:
a. If a person is covered by 2 or more Plans
that compute their benefit payments on the
basis of usual and customary fees or
relative value schedule reimbursement
methodology or other similar
reimbursement methodology, any amount
in excess of the highest reimbursement
amount for a specific benefit is not an
Allowable expense .
b. If a person is covered by 2 or more Plans
that provide benefits or services on the
basis of negotiated fees, an amount in
excess of the highest of the negotiated fees
is not an Allowable expense.
c. If a person is covered by one Plan that
calculates its benefits or services on the
basis of usual and customary fees or
relative value schedule reimbursement
methodology or other similar
reimbursement methodology and another
Plan that provides its benefits or services
on the basis of negotiated fees, the Primary
Plan's payment arrangement shall be the
Allowable expense for all Plans. However,
if the provider has contracted with the
Secondary Plan to provide the benefit or
service for a specific negotiated fee or
payment amount that is different than the
Primary Plan's payment arrangement and if
the provider's contract permits, the negotiated
fee or payment shall be the Allowable
expense used by the Secondary Plan to
determine its benefits.
d. The amount of any benefit reduction by the
Primary Plan because a covered person has
failed to comply with the Plan provisions is
not an Allowable expense. Examples of
these types of Plan provisions include second
surgical opinions, precertification of
admissions, and preferred provider
arrangements.
3. Closed Panel Plan is a Plan that provides health
care benefits to covered persons primarily in the
form of services through a panel of providers that
have contracted with or are employed by the
Plan, and that excludes coverage for services
provided by other providers, except in cases of
emergency or referral by a panel member.
4. Custodial parent is the parent awarded custody
by a court decree or, in the absence of a court
decree, is the parent with whom the child resides
more than one half of the calendar year excluding
any temporary visitation.
C. ORDER OF BENEFIT DETERMINATION
RULES
When a person is covered by two or more Plans, the
rules for determining the order of benefit payments
are as follows
1. The Primary Plan pays or provides its benefits
according to its terms of coverage and without
regard to the benefits of under any other Plan.
2. Except as provided in the paragraph below, a
Plan that does not contain a coordination of
benefits provision that is consistent with this
regulation is always primary unless the
provisions of both Plans state that the complying
Plan is primary.
a. Coverage that is obtained by virtue of
membership in a group that is designed to
supplement a part of a basic package of
benefits and provides that this supplementary
coverage shall be excess to any other parts of
the Plan provided by the contract holder.
Examples of these types of situations are
major medical coverages that are
superimposed over base Plan hospital and
surgical benefits, and insurance type
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D-OH-3502A V4 01/2012
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coverages that are written in connection
with a “Closed Panel Plan” to provide out-
of-network benefits.
3. A Plan may consider the benefits paid or
provided by another Plan in calculating
payment of its benefits only when it is
secondary to that other Plan.
4. Each Plan determines its order of benefits using
the first of the following rules that apply:
a. Non-Dependent or Dependent. The Plan
that covers the person other than as a
dependent, for example as an employee,
member, policyholder, subscriber or retiree
is the Primary Plan and the Plan that covers
the person as a dependent is the Secondary
Plan. However, if the person is a Medicare
beneficiary and, as a result of federal law,
Medicare is secondary to the Plan covering
the person as a dependent, and primary to
the Plan covering the person as other than a
dependent (e.g. a retired employee), then
the order of benefits between the two Plans
is reversed so that the Plan covering the
person as an employee, member,
policyholder, subscriber or retiree is the
Secondary Plan and the other Plan is the
Primary Plan.
b. Dependent child covered under more than
one Plan. Unless there is a court decree
stating otherwise, when a dependent child
is covered by more than one Plan the order
of benefits is determined as follows:
i. For a dependent child whose parents
are married or are living together,
whether or not they have ever been
married:
(a) The Plan of the parent whose
birthday falls earlier in the calendar
year is the Primary Plan; or
(b) If both parents have the same
birthday, the Plan that has covered
the parent the longest is the
Primary Plan.
(c) However, if one spouse's Plan has
some other coordination rule (for
example, a "gender rule" which
says the father's Plan is always
primary), we will follow the rules
of that Plan.
ii. For a dependent child whose parents are
divorced or separated or not living
together, whether or not they have ever
been married:
(a) If a court decree states that one of the
parents is responsible for the
dependent child's health care
expenses or health care coverage and
the Plan of that parent has actual
knowledge of those terms, that Plan
is primary. This rule applies to Plan
years commencing after the Plan is
given notice of the court decree;
(b) If a court decree states that both
parents are responsible for the
dependent child's health care
expenses or health care coverage, the
provisions of Subparagraph (a) above
shall determine the order of benefits;
(c) If a court decree states that the
parents have joint custody without
specifying that one parent has
responsibility for the health care
expenses or health care coverage of
the dependent child, the provisions of
Subparagraph (a) above shall
determine the order of benefits; or
(d) If there is no court decree allocating
responsibility for the dependent
child's health care expenses or health
care coverage, the order of benefits
for the child are as follows:
1) The Plan covering the Custodial
parent;
2) The Plan covering the spouse of
the Custodial parent;
3) The Plan covering the non-
custodial parent; and then
4) The Plan covering the spouse of
the non-custodial parent.
(e) For a dependent child covered under
more than one Plan of individuals
who are not the parents of the child,
the provisions of Subparagraph (i) or
(ii) above shall determine the order
of benefits as if those individuals
were the parents of the child.
iii. Active employee or retired or laid-off
employee. The Plan that covers a person
as an active employee, that is, an
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D-OH-3502A V4 01/2012
15
employee who is neither laid off nor
retired, is the Primary Plan. The Plan
covering that same person as a retired
or laid-off employee is the Secondary
Plan. The same would hold true if a
person is a dependent of an active
employee and that same person is a
dependent of a retired or laid-off
employee. If the other Plan does not
have this rule, and as a result, the Plans
do not agree on the order of benefits,
this rule is ignored. This rule does not
apply if the rule labeled 4(a) can
determine the order of benefits.
iv. COBRA or state continuation
coverage. If a person whose coverage
is provided pursuant to COBRA or
under a right of continuation provided
by state or other federal law is covered
under another Plan, the Plan covering
the person as an employee, member,
subscriber or retiree or covering the
person as a dependent of an employee,
member, subscriber or retiree is the
Primary Plan and the COBRA or state
or other federal continuation coverage
is the Secondary Plan. If the other Plan
does not have this rule, and as a result,
the Plans do not agree on the order of
benefits, this rule is ignored. This rule
does not apply if the rule labeled 4(a)
can determine the order of benefits.
v. Longer or shorter length of coverage.
The Plan that covered the person as an
employee, member, policyholder,
subscriber or retiree longer is the
Primary Plan and the Plan that covered
the person the shorter period of time is
the Secondary Plan.
vi. If the preceding rules do not determine
the order of benefits, the Allowable
expenses shall be shared equally
between the Plans meeting the
definition of Plan. In addition, this
Plan will not pay more than it would
have paid had it been the Primary Plan.
D. EFFECT ON THE BENEFITS OF THIS PLAN
1. When this Plan is secondary, it may reduce its
benefits so that the total benefits paid or
provided by all Plans during a Plan year are not
more than the total Allowable expenses. In
determining the amount to be paid for any
claim, the Secondary Plan will calculate the
benefits it would have paid in the absence of
other health care coverage and apply that
calculated amount to any Allowable expense
under its Plan that is unpaid by the Primary Plan.
The Secondary Plan may then reduce its payment
by the amount so that, when combined with the
amount paid by the Primary Plan, the total
benefits paid or provided by all Plans for the
claim do not exceed the total Allowable expense
for that claim. In addition, the Secondary Plan
shall credit to its Plan deductible any amounts it
would have credited to its deductible in the
absence of other health care coverage.
2. If a covered person is enrolled in two or more
Closed Panel Plans and if, for any reason,
including the provision of service by a non-panel
provider, benefits are not payable by one Closed
Panel Plan, COB shall not apply between that
Plan and other Closed Panel Plans.
E. RIGHT TO RECEIVE AND RELEASE NEEDED
INFORMATION
Certain facts about health care coverage and services
are needed to apply these COB rules and to determine
benefits payable under this Plan and other Plans.
RLHICA may get the facts it needs from or give them
to other organizations or persons for the purpose of
applying these rules and determining benefits payable
under this Plan and other Plans covering the person
claiming benefits. RLHICA need not tell, or get the
consent of, any person to do this. Each person
claiming benefits under this Plan must give RLHICA
any facts it needs to apply those rules and determine
benefits payable.
F. FACILITY OF PAYMENT
A payment made under another Plan may include an
amount that should have been paid under this Plan. If
it does, RLHICA may pay that amount to the
organization that made that payment. That amount
will then be treated as though it were a benefit paid
under this Plan. RLHICA will not have to pay that
amount again. The term "payment made" includes
providing benefits in the form of services, in which
case "payment made" means the reasonable cash
value of the benefits provided in the form of services.
G. RIGHT OF RECOVERY
If the amount of the payments made by RLHICA is
more than it should have paid under this COB
provision, it may recover the excess from one or more
of the persons it has paid or for whom it has paid, or
any other person or organization that may be
responsible for the benefits or services provided for
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the covered person. The "amount of the payments
made" includes the reasonable cash value of any
benefits provided in the form of services.
H. COORDINATION DISPUTES
If you believe that RLHICA has not paid a claim
properly, you should first attempt to resolve the
problem by contacting us, 1-866-569-8654. If you
are not satisfied, you may call the Ohio Department of
Insurance for instructions on filing a consumer
complaint. Call 1-800-686-1526 or visit the
Department’s website at http://insurance.ohio.gov.
IX. Disputed Claims
Procedure
If you receive notice of an Adverse Benefit
Determination, and if you think that RLHICA
incorrectly denied all or part of your claim, you or your
Dentist should contact RLHICA’s Customer Services
Department and ask them to check the claim to make sure
it was processed correctly. You may do this by calling the
toll-free number, 1-866-569-8654 and speaking to a
telephone advisor. You may also mail your inquiry to the
Customer Services Department at P.O. Box 1596,
Indianapolis, IN 46206-1596.
When writing, please enclose a copy of your explanation
of benefits and describe the problem. Be sure to include
your name, telephone number, the date, and any
information you would like considered about your claim.
This inquiry is not required and should not be considered a
formal request for review of a denied claim. RLHICA
provides this opportunity for you to describe problems and
submit explanatory information that might indicate your
claim was improperly denied and allow RLHICA to
correct any errors quickly and without delay.
Whether or not you have asked RLHICA informally to
recheck its initial determination, you can submit your
claim to a formal review through the Disputed Claims
Appeal Procedure described below.
If you receive notice of an Adverse Benefit
Determination, you, or your authorized representative,
should seek a review as soon as possible, but you must
file your request for review within 180 days of the date
on which you receive your notice of the Adverse Benefit
Determination which you are asking RLHICA to review.
To request a formal review of your claim, send your
request in writing to:
Dental Director
Renaissance Dental - RLHICA
P.O. Box 1596
Indianapolis, IN 46206-1596
Please include your name and address, the Certificate
Holder’s Social Security number, the reason why you
believe your claim was wrongly denied, and any other
information you believe supports your claim. You also
have the right to review This Plan and any documents
related to it. If you would like a record of your request
and proof that it was received by RLHICA, you should
mail it certified mail, return receipt requested.
The Dental Director, or any other person(s) reviewing
your claim, will not be the same as, nor will they be
subordinate to, the person(s), who initially decided your
claim. The reviewer will grant no deference to the prior
decision about your claim, but rather will assess the
information, including any additional information that
you have provided, as if he/she were deciding the claim
for the first time. The reviewer’s decision will take into
account all comments, documents, records and other
information relating to your claim even if the information
was not available when your claim was initially decided.
If the decision is based, in whole or in part, on a dental or
medical judgment (including determinations with respect
to whether a particular treatment, drug, or other item is
experimental, investigational or not medically necessary
or appropriate), the reviewer will, as necessary, consult a
dental health care professional with appropriate training
and experience. The dental health care professional will
not be the same individual, or that person's subordinate,
consulted during the initial determination.
The reviewer will make his/her determination on review
within 60 days of his/her receipt of your request. If your
claim is denied on review (in whole or in part), you will
be notified in writing. The notice of an Adverse Benefit
Determination during the Disputed Claims Appeal
Procedure will meet the requirements described below
under the heading "Manner and Content of Notice."
Manner and Content of Notice
Your notice of an Adverse Benefit Determination will
inform you of the specific reasons(s) for the denial, the
pertinent Policy provisions(s) on which the denial is
based, the applicable review procedures for dental claims,
including applicable time limits, and that you are entitled
to access, free of charge, upon request, all documents,
records and other information relevant to your claim. The
notice will also contain a description of any additional
materials necessary to complete your claim, an
explanation of why such materials are necessary, and a
statement that you have a right to bring a civil action in
court if you receive an Adverse Benefit Determination
after your claim has been completely reviewed according
to this Disputed Claims Appeal Procedure. The notice
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D-OH-3502A V4 01/2012
17
will also reference any internal rule, guideline, protocol,
or similar document or criteria relied on in making the
Adverse Benefit Determination, and will include a
statement that a copy of such rule, guideline or protocol
may be obtained upon request at no charge. If the
Adverse Benefit Determination is based on a matter of
medical judgment or medical necessity, the notice will
also contain an explanation of the scientific or clinical
judgment on which the determination was based, or a
statement that a copy of the basis for the scientific or
clinical judgment can be obtained upon request at no
charge.
If you (a) need the assistance of a governmental
agency that regulates insurance; or (b) have a
complaint you have been unable to resolve with your
insurer, you may also contact the Consumer
Services Division of the Ohio Department of
Insurance, 50 W. Town Street, Third Floor, Suite
300, Columbus, OH 43215.
X. Termination of Coverage
RLHICA must give your employer or organization at
least 45 days advance notice of cancellation, expiration,
nonrenewal, or change in rates. In the event RLHICA
chooses to terminate the Policy due to nonpayment of
premium, RLHICA will give your employer or
organization notice of the termination within 45 days
after the premium due date. The effective date of such
termination shall be the first day of the period for which
the premium is due.
Your RLHICA coverage may be automatically
terminated:
1. When your employer or organization advises
RLHICA to terminate your coverage;
2. On the last day of the month for which your
employer or organization has failed to pay
RLHICA;
3. Or for any other reason stated in the Policy.
A person whose eligibility is terminated may be eligible
to transfer to an individual direct payment contract with
RLHICA. Please contact RLHICA to obtain further
information.
XI. Continuation of
Coverage
A. Loss of Eligibility During Treatment
1. If you and/or an Eligible Dependent lose
eligibility while receiving dental treatment, only
those Covered Services received while you
and/or your Eligible Dependent were eligible
under the Policy will be payable.
2. Certain procedures begun before the loss of
eligibility may be covered if the services were
completed within a 30 day period measured from
the date of termination. In those cases, RLHICA
evaluates those services in progress to determine
what portion may be paid by RLHICA. The
difference between RLHICA’s payment and the
total fee for those procedures is your
responsibility.
B. Continuation Coverage
If your employer or organization is required to comply
with provisions under the Consolidated Omnibus
Budget Reconciliation Act of 1985 (“COBRA”) and
your coverage would otherwise end, you and/or your
covered Eligible Dependents may have the right under
certain circumstances to continue coverage in the
group health plans sponsored by your employer or
organization, at your expense, beyond the time
coverage would normally end.
COBRA continuation coverage may be available if
your coverage or a covered Eligible Dependent’s
coverage would otherwise end because of one of the
following COBRA qualifying events:
1. Voluntary or involuntary termination of
employment for any reason other than your gross
misconduct;
2. Reduction in the number of hours worked so that
you are no longer an eligible employee under the
terms of the group health plan;
3. Divorce or legal separation;
4. Death;
5. Loss of dependent status under the terms of the
group health plan; or
6. You become entitled to Medicare (if applicable).
If you are called to active duty in the armed forces of
the United States, you and your covered Eligible
Dependents may also have continuation coverage
rights under the Uniformed Services Employment and
Reemployment Rights Act (“USERRA”).
If you believe you are entitled to continuation coverage
either under COBRA or USERRA, you should contact
your employer or organization to receive additional
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D-OH-3502A V4 01/2012
18
information about your rights and to learn more
about the applicable procedures for applying for
such continuation coverage.
C. Continuation Coverage – Death of Certificate
Holder
Upon the death of the Certificate Holder, coverage
for Eligible Dependents (if any) shall continue for a
period of 90 days, subject to the termination
provisions found in Section III and Section X of
this Certificate.
D. Continuation Coverage – Eligible Dependents
Eligible Dependents may elect to continue coverage
under this Certificate in the event of the divorce,
retirement or death of the Certificate Holder. To
elect coverage, Eligible Dependents should contact
the Certificate Holder’s employer or organization
immediately following the occurrence of one of the
above-mentioned events.
E. Continuation Coverage – Total Disability
In the event the Policy is terminated for any reason,
the Benefits paid pursuant to the Policy shall
continue for a period of 90 days in the event of total
disability (on the date of such termination) of the
Certificate Holder or an Eligible Dependent.
XII. General Conditions
Change of Status
You must notify RLHICA through your employer or
organization, of any event causing a change in the
status of an Eligible Dependent. Events that can affect
the status of an Eligible Dependent include, but are not
limited to, marriage, birth, death, divorce, and entrance
into military service.
Assignment
Benefits to you or your Eligible Dependent are for the
personal benefit of you or your Eligible Dependent and
cannot be transferred or assigned. You or your Eligible
Dependent, however, may assign Benefits to the Dentist
who rendered Covered Services under This Plan.
Benefits paid pursuant to such assignment shall
discharge the obligation of RLHICA with respect to the
amount of the Benefits so paid.
Subrogation
If RLHICA pays a claim for which another person or
company is liable, RLHICA has the right to recover its
payment from the other person or company.
Obtaining and Releasing Information
While you are covered by RLHICA, you agree to provide
RLHICA with any information it needs to process your
claims and administer your Benefits. This includes
allowing RLHICA to have access to your dental records.
Dentist-Patient Relationship
You and your Eligible Dependents have the freedom to
choose any Dentist. Each Dentist maintains the dentist-
patient relationship with the patient and is solely
responsible to the patient for dental advice and treatment
and any resulting liability.
Late Claims Submission
Except as otherwise provided in this Certificate, RLHICA
will not honor and no payment will be made for services,
items or supplies if a claim for those services, items or
supplies has not been received by RLHICA within one
year from the date that the services, items or supplies
were provided.
Change of Certificate or Policy
No agent has the authority to change any provisions in
this Certificate or the provisions of the Policy on which it
is based. No changes to this Certificate or the underlying
Policy are valid unless approved in writing by an officer
of RLHICA.
Note: This Certificate and the Policy are subject to
change if, in the future, federal and state privacy laws and
regulations require RLHICA or your employer or
organization to comply with such laws and regulations.
Should any such change to this Certificate or the Policy
be necessary by law, you will receive written notice from
RLHICA informing you of the reasons for any change to
this Certificate or the Policy and the process by which
you will receive an amended Certificate or the amended
section of this Certificate.
Legal Actions
No legal action may be brought to recover on this Policy
within 60 days after written proof of loss has been given
as required by this Policy, unless otherwise provided by
applicable state law. No such action may be brought after
the expiration of three years after the time written proof
of loss is required to be given. This provision does not
preclude the Policyholder or Certificate Holder from
seeking a decision from a jury trial once all administrative
appeals have been exhausted.
Representations
In the absence of fraud, all statements made by your
employer or organization or by you or your Eligible
Dependents, shall be deemed to be representations and
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D-OH-3502A V4 01/2012
19
not warranties. No such statement shall be used in
defense to a claim under the Policy, unless it is
contained in a written application.
SAMPLE
SAMPLE
D-202A 01/2012
CERTIFICATE IN-NETWORK DENTIST BENEFIT RIDER
By attachment of this rider, the Certificate is amended as follows:
This Certificate is amended to provide Benefits that are based on whether you or your Eligible Dependent
receives dental services from an In-Network Dentist or an Out-of-Network Dentist.
If you or your Eligible Dependents receive Covered Services from an Out-of-Network Dentist, Benefits
may be less than the amount that would have otherwise been payable with an In-Network Dentist.
However, if you or your Eligible Dependents require emergency treatment and receive Covered Services
from an Out-of-Network Dentist, Covered Services for the emergency care rendered during the course of
the emergency will be treated as if they had been provided by an In-Network Dentist. Also, if you or your
Eligible Dependents receive Covered Services that are not of the type provided by any In-Network
Dentist, these Covered Services will be treated as if they had been provided by an In-Network Dentist.
The Benefits for both In-Network and Out-of-Network Dentists are shown in the Summary of Dental Plan
Benefits Section.
Payment of Dental Bills When You See an In-Network Dentist
If you or your Eligible Dependents receive Covered Services from an In-Network Dentist, the fee for
services has already been agreed to between the Dentist and RLHICA. In-Network Dentists accept
these pre-negotiated fees as payment in full for the dental care provided. You will be responsible for
paying the Dentist that percentage of the Allowed Amount listed in the "You Pay" column of the
Summary of Dental Plan Benefits for In-Network Dentists for the categories of services rendered.
You are also responsible for any charges for optional treatment or specific exclusions/limitations of
the Certificate.
Payment of Dental Bills When You See an Out-of-Network Dentist
If you or your Eligible Dependents receive Covered Services from an Out-of-Network Dentist, payment
will be based upon the percentage of the Allowed Amount that is set forth in the Summary of Dental
Plan Benefits Section. You will be responsible for paying the Dentist that percentage of the Allowed
Amount listed in the “You Pay” column of the Summary of Dental Plan Benefits Section for Out-of-
Network Dentists for the categories of services rendered. In addition, if the Submitted Amount for an
Out-of-Network Dentist is more than the Allowed Amount, you will also be responsible for paying the
Dentist the difference between the Submitted Amount and the Allowed Amount.
You are also responsible for any charges for optional treatment or specific exclusions/limitations of the
Certificate.
Definitions (As used in this rider):
Allowed Amount – is revised to mean the maximum dollar amount upon which RLHICA will base
Benefits. For services rendered or items provided by an In-Network Dentist, the Allowed Amount is a
pre-negotiated fee that the provider has agreed to accept as payment in full. For services rendered or items
provided by an Out-of-Network Dentist, RLHICA determines the Allowed Amount using statistically
valid claims data submitted to RLHICA and its affiliates which show the most frequently charged fees by
providers in the same geographic areas for comparable services or supplies. The claims data and fees are
updated periodically using the most current codes and nomenclature developed and maintained by the
American Dental Association. This definition is only applicable if the Allowed Amount method for
Benefits is shown in the Summary of Dental Plan Benefits Section.
SAMPLE
D-202A 01/2012
In-Network Dentist – means a preferred provider Dentist who has entered into a contract to provide
Covered Services for pre-negotiated fees that the Dentist has agreed to accept as payment in full. You
will be provided with a current list of In-Network Dentists.
Out-of-Network Dentist – means a Dentist who has not entered into a contract to provide Covered
Services for pre-negotiated fees.
This rider does not change, waive or extend any part of the Certificate other than as set forth above.
This rider is effective at the same time as the Certificate.
Renaissance Life & Health Insurance Company of America
Robert P. Mulligan, President and Chief Executive Officer
SAMPLE
Residents of Ohio who purchase life insurance, annuities or health insurance should know that the
insurance companies licensed in this state to write these types of insurance are members of the
Ohio Life and Health Insurance Guaranty Association. The purpose of this association is to
assure that policyholders will be protected, within limits, in the unlikely event that a member
insurer becomes financially unable to meet its obligations. If this should happen, the guaranty
association will assess its other member insurance companies for the money to pay the claims of
insured persons who live in this state and, in some cases, to keep coverage in force. The valuable
extra protection provided by these insurers through the guaranty association is not unlimited,
however. And, as noted in the box below, this protection is not a substitute for consumers' care
in selecting companies that are well-managed and financially stable.
The state law that provides for this safety-net coverage is called the Ohio Life and Health
Insurance Guaranty Association Act. On the back of this page is a brief summary of this law's
coverages, exclusions and limits. This summary does not cover all provisions of the law nor does
it in any way change anyone's rights or obligations under the act or the rights or obligations of the
guaranty association.
The Ohio Life and Health Insurance Guaranty Association may not provide coverage for this policy. If coverage is provided, it may be subject to substantial limitations or exclusions, and require continued residency in Ohio. You should not rely on coverage by the Ohio Life and Health Insurance Guaranty Association in selecting an insurance company or in selecting an insurance policy.
Coverage is NOT provided for your policy or any portion of it that is not guaranteed by the insurer or for which you have assumed the risk, such as a variable contract sold by prospectus. You should check with your insurance company representative to determine if you are only covered in part or not covered at all.
Insurance companies or their agents are required by law to give or send you
this notice. However, insurance companies and their agents are prohibited by
law from using the existence of the guaranty association to induce you to
purchase any kind of insurance policy.
Ohio Life and Health Insurance Guaranty Association 1840 Mackenzie Drive Columbus, OH 43220
Ohio Department of Insurance 50 West Town Street Third Floor-Suite 300 Columbus, OH 43215
Notice Concerning Coverage Limitations and Exclusions under the Ohio Life
and Health Insurance Guaranty Association
Act
SAMPLE
COVERAGE
Generally, individuals will be protected by the life and health insurance guaranty association if
they live in Ohio and hold a life or health insurance contract, annuity contract,
unallocated annuity contract; if they are insured under a group insurance contract, issued
by a member insurer; or if they are the payee or beneficiary of a structured settlement
annuity contract. The beneficiaries, payees or assignees of insured persons are protected as
well, even if they live in another state.
EXCLUSIONS FROM COVERAGE
However, persons holding such policies are not protected by this association if:
• they are eligible for protection under the laws of another state (this may occur when the
insolvent insurer was incorporated in another state whose guaranty association protects
insureds who live outside that state);
• the insurer was not authorized to do business in this state;
• their policy was issued by a medical, health or dental care corporation, an HMO, a fraternal
benefit society, a mutual protective association or similar plan in which the policyholder is subject to future assessments, or by an insurance exchange.
The association also does not provide coverage for:
• any policy or portion of a policy which is not guaranteed by the insurer or for which the
individual has assumed the risk, such as a variable contract sold by prospectus;
• any policy of reinsurance (unless an assumption certificate was issued);
• interest rate yields that exceed an average rate;
• dividends;
• credits given in connection with the administration of a policy by a group contract holder;
• employers’ plans to the extent they are self-funded (that is, not insured by an insurance
company, even if an insurance company administers them).
LIMITS ON AMOUNT OF COVERAGE
The act also limits the amount the association is obligated to pay out: The association cannot
pay more than what the insurance company would owe under a policy or contract. Also, for
any one insured life, the association will pay a maximum of $300,000, except as specified
below, no matter how many policies and contracts there were with the same company, even if
they provided different types of coverages. The association will not pay more than $100,000
in cash surrender values, $500,000 in major medical insurance benefits, $300,000 in
disability or long-term care insurance benefits, $100,000 in other health insurance benefits,
$250,000 in present value of annuities, or $300,000 in life insurance death benefits. Again,
no matter how many policies and contracts there were with the same company, and no matter
how many different types of coverages, the association will pay a maximum of $300,000,
except for coverage involving major medical insurance benefits, for which the maximum of
all coverages is $500,000.
Note to benefit plan trustees or other holders of unallocated annuities (G/Cs, DA Cs, etc.)
covered by the act: For unallocated annuities that fund governmental retirement plans under
§§401, 403(b) or 457 of the Internal Revenue Code, the limit is $250,000 in present value of
annuity benefits including net cash surrender and net cash withdrawal per participating
individual. In no event shall the association be liable to spend more than $300,000 in the
aggregate per individual, except as noted above. For covered unallocated annuities that fund
other plans, a special limit of $1,000,000 applies to each contract holder, regardless of the
number of contracts held with the same company or number of persons covered. In all cases, of
course, the contract limits also apply.
For more information about the Ohio Life & Health Insurance Guaranty Association, visit our website at: www. olhiga.org.
As of 12/22/2015
SAMPLE
NOTICE OF PRIVACY PRACTICESDate of this notice: February 12, 2016
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This notice describes the privacy practices of Delta Dental Plan of Michigan, Inc., Delta Dental Plan of Ohio, Inc., Delta Dental Plan of Indiana, Inc., Delta Dental Plan of Arkansas, Inc., Delta Dental of Kentucky, Inc., Delta Dental Plan of New Mexico, Inc., Delta Dental of North Carolina, Delta Dental of Tennessee, Renaissance Life & Health Insurance Company of America, Renaissance Health Insurance Company of New York, and Renaissance Systems & Services, LLC (collectively, “we” or ”us” or the “Plan”). These entities have designated themselves as a single affiliated covered entity for purposes of the privacy rules under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), and each has agreed to abide by the terms of this notice and may share protected health information with each other as necessary for treatment, payment or to carry out health care operations, or as otherwise permitted by law.
The HIPAA Privacy Rule protects only certain medical information known as “protected health information” (“PHI”). Generally, PHI is individually identifiable health information, including demographic information, collected from you or received by a health care provider, a health care clearinghouse, a health plan or your employer on behalf of a group health plan that relates to:
1. your past, present or future physical or mental health or condition;2. the provision of health care to you; or3. the past, present or future payment for the provision of health care
to you.
We are required by law to maintain the privacy of your health information and to provide you with this notice of our legal duties and privacy practices with respect to your health information. We are committed to protecting your health information.
We comply with the provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act. We maintain a breach reporting policy and have in place appropriate safeguards to track required disclosures and meet appropriate reporting obligations. We will notify you promptly in the event a breach occurs that may have compromised the security or privacy of your PHI. In addition, we comply with the “Minimum Necessary” requirements of HIPAA and the HITECH amendments.
For more information concerning this notice please see: www.hhs.gov/hipaa/for-individuals/notice-privacy-practices/index.html.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU The following categories describe different ways that we may use or disclose your PHI.
For treatment—We may use or disclose your PHI to facilitate medical treatment or services by providers. We may disclose PHI about you to providers, including dentists, doctors, nurses, or technicians, who are involved in taking care of you. For example, we might disclose information about your prior dental X-ray to a dentist to determine if the prior X-ray affects your current treatment.
For payment—We may use or disclose PHI about you to obtain payment for your treatment and to conduct other payment-related activities, such as determining eligibility for Plan benefits, obtaining customer payment for benefits, processing your claims, making coverage decisions, administering Plan benefits and coordinating benefits.
For health care operations—We may use and disclose PHI about you for other Plan operations, including setting rates, conducting quality assessment and improvement activities, reviewing your treatment, obtaining legal and audit services, detecting fraud and abuse, business planning and other general administration activities. In accordance with
the Genetic Information and Nondiscrimination Act of 2008, we are prohibited from using your genetic information for underwriting purposes.
To Business Associates—We may contract with individuals or entities known as Business Associates to perform various functions or to provide certain types of services on the Plan’s behalf. In order to perform these functions or provide these services, Business Associates may receive, create, maintain, use and/or disclose your PHI, but only if they agree in writing with the Plan to implement appropriate safeguards regarding your PHI. For example, the Plan may disclose your PHI to a Business Associate to administer claims or provide support services, such as utilization management, quality assessment, billing and collection or audit services, but only after the Business Associate enters into a Business Associate Agreement with the Plan.
Health-related benefits and services—We may use or disclose health information about you to communicate to you about health-related benefits and services. For example, we may communicate to you about health-related benefits and services that add value to, but are not part of, your health plan.
To avert a serious threat to health or safety—We may use and disclose PHI about you to prevent or lessen a serious and imminent threat to the health or safety of a person or the general public.
Military and veterans—If you are a member of the armed forces, we may release PHI about you if required by military command authorities.
Worker’s compensation—We may release PHI about you as necessary to comply with worker’s compensation or similar programs.
Public health risks—We may release PHI about you for public health activities, such as to prevent or control disease, injury or disability, or to report child abuse, domestic violence, or disease or infection exposure.
Health oversight activities—We may release PHI to help health agencies during audits, investigations or inspections.
Lawsuits and disputes—If you are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order. We also may disclose PHI about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law enforcement—We may release PHI if asked to do so by a law enforcement official:
• In response to a court order, subpoena, warrant, summons or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
• About a death we believe may be the result of criminal conduct; and• In emergency circumstances to report a crime; the location of the
crime or victims; or the identity, description or location of the person who committed the crime.
Coroners, medical examiners and funeral directors—We may release PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.
National security and intelligence activities—We may release PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
To Plan Sponsor—We may disclose your PHI to certain employees of the Plan Sponsor (i.e., the company) for the purpose of administering the Plan. These employees will only use or disclose your PHI as necessary to perform Plan administrative functions or as otherwise required by HIPAA.
Disclosure to others—We may use or disclose your PHI to your family members and friends who are involved in your care or the payment
SAMPLE
for your care. We may also disclose PHI to an individual who has legal authority to make health care decisions on your behalf.
REQUIRED DISCLOSURESThe following is a description of disclosures of your PHI the Plan is required to make:
As required by law—We will disclose PHI about you when required to do so by federal, state or local law. For example, we may disclose PHI when required by a court order in a litigation proceeding, such as a malpractice action.
Government audits—The Plan is required to disclose your PHI to the secretary of the United States Department of Health and Human Services when the secretary is investigating or determining the Plan’s compliance with HIPAA.
Disclosures to you—Upon your request, the Plan is required to disclose to you the portion of your PHI that contains medical records, billing records, and any other records used to make decisions regarding your health care benefits.
WRITTEN AUTHORIZATIONWe will use or disclose your PHI only as described in this notice. It is not necessary for you to do anything to allow us to disclose your PHI as described here. If you want us to use or disclose your PHI for another purpose, you must authorize us in writing to do so. For example, we may use your PHI for research purposes if you provide us with written authorization to do so. You may revoke your authorization in writing at any time. When we receive your revocation, it will be effective only for future uses and disclosures. It will not be effective for any PHI that we may have used or disclosed in reliance upon your written authorization. We will never sell your PHI or use it for marketing purposes without your express written authorization. We cannot condition treatment, payment, enrollment in a health plan, or eligibility for benefits on your agreement to sign an authorization.
ADDITIONAL INFORMATION REGARDING USES OR DISCLOSURES OF YOUR PHIFor additional information regarding the ways in which we are allowed or required to use of disclosure your PHI, please see www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html.
YOUR RIGHTS REGARDING PHI THAT WE MAINTAIN You have the following rights regarding PHI we maintain about you:
Your right to inspect and copy your PHI—You have the right to inspect and copy your PHI. You must submit your request in writing and if you request a copy of the information, we may charge you a reasonable fee to cover expenses associated with your request. A copy will be provided within 30 days of your request.
The Plan may deny your request to inspect and copy PHI in certain limited circumstances. If you are denied access to PHI, you may request that the denial be reviewed by submitting a written request to the contact person listed below.
Your right to amend incorrect or incomplete information—If you believe that the PHI the Plan has about you is incorrect or incomplete, you may request that we change your PHI by submitting a written request. You also must provide a reason for your request. We are not required to amend your PHI but if we deny your request, we will provide you with information about our denial and how you can disagree with the denial within 60 days of your request.
Your right to request restrictions on disclosures to health plans—Where applicable, you may request that restrictions be placed on disclosures of your PHI.
Your right to an accounting of disclosures we have made—You may request an accounting of disclosures of your PHI that we have made, except for disclosures we made to you or pursuant to your written authorization, or that were made for treatment, payment or health care
operations. You must submit your request in writing. Your request may specify a time period of up to six years prior to the date of your request. We will provide one list of disclosures to you per 12-month period free of charge; we may charge you for additional lists.
Your right to request restrictions on uses and disclosures—You have the right to request restrictions or limitations on the way that we use or disclose PHI. You must submit a request for such restrictions in writing, including the information you wish to limit, the scope of the limitation and the persons to whom the limits apply. We may deny your request.
Your right to request confidential communications through a reasonable alternative means or at an alternative location—You may request that we direct confidential communications to you in an alternative manner (i.e., by facsimile or email). You must submit your request in writing. We are not required to agree to your request, however, we will accommodate your request if doing otherwise would place you in any danger.
Your right to a paper copy of this notice—To obtain a paper copy of this notice or a more detailed explanation of these rights, send us a written request at the address listed below. You may also obtain a copy of this notice at one of our websites:
• www.deltadentalmi.com,• www.deltadentaloh.com,• www.deltadentalin.com,• www.deltadentalar.com • www.deltadentalky.com,• www.deltadentalnc.com,• www.deltadentalnm.com,• www.deltadentaltn.com,• www.renaissancedental.com, or• www.rss-llc.com.
Your right to appoint a personal representative—Upon receipt of appropriate documentation appointing an individual as your personal representative, medical power of attorney or legal guardian, that individual will be permitted to act on your behalf and make decisions regarding your health care.
CHANGES TO THIS NOTICEWe may amend this Notice of Privacy Practices at any time in the future and make the new notice provisions effective for all PHI that we maintain. We will advise you of any significant changes to the notice. We are required by law to comply with the current version of this notice.
COMPLAINTSIf you believe your privacy rights or rights to notification in the event of a breach of your PHI have been violated, you may file a complaint with us or with the Office of Civil Rights. Complaints about this notice or about how we handle your PHI should be submitted in writing to the contact person listed below.
A complaint to the Office of Civil Rights should be sent to Office of Civil Rights, U.S. Department of Health & Human Services, 200 Independence Ave., SW, Washington, D.C. 20201, 877-696-6775. You also may visit OCR’s website at www.hhs.gov/hipaa/filing-a-complaint/index.html for more information.
You will not be penalized, or in any other way retaliated against for filing a complaint with us or the Office of Civil Rights.
SEND ALL WRITTEN REQUESTS REGARDING THIS PRIVACY NOTICE TO:Jonathan S. Groat Chief Privacy Officer PO Box 30416 Lansing, MI 48909-7916 517-347-5451 (TTY users call 711)
Para asistencia en español, llame al número de servicio al cliente (customer service) que aparece en el reverso de su tarjeta para miembros.
This document is also available in alternative formats upon request and at no cost to persons with disabilities.
Notice of Privacy Policies LGL 2/12/16
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FACTS
Why?
Rev. 9/2015 WHAT DOES RENAISSANCE LIFE & HEALTH INSURANCE COMPANY OF AMERICA DO WITH YOUR PERSONAL INFORMATION?
Financial companies choose how they share your personal information. Federal law givesconsumers the right to limit some but not all sharing. Federal law also requires us to tellyou how we collect, share, and protect your personal information. Please read this noticecarefully to understand what we do.
What? The types of personal information we collect and share depend on the product or serviceyou have with us. This information can include:
Social Security number and Insurance claim informationTransaction history and Medical informationCredit card payments and Employment information
When you are no longer our customer, we continue to share your information as describedin this notice.
Why? All financial companies need to share members’ personal information to run their everydaybusiness. In the section below, we list the reasons financial companies can share theirmembers’ personal information; the reasons Renaissance Life & Health InsuranceCompany of America chooses to share; and whether you can limit this sharing.
For our everyday business purposes –such as to process your transactions, maintain youraccount(s), respond to court orders and legalinvestigations, or report to credit bureaus
For our marketing purposes –to offer our products and services to you
For joint marketing with other financial companies
For our affiliates’ everyday business purposes –information about your transactions and experiences
For our affiliates’ everyday business purposes –information about your creditworthiness
For nonaffiliates to market to you
Yes
Yes
No
Yes
No
No
No
No
We do not share
No
We do not share
We do not share
Reasons we can share your personal informationDoes Renaissance Life
& Health InsuranceCompany of America
share?
Can you limit this sharing?
Questions? Call 517-347-5451 or go to www.renaissancedental.com (TTY users call 711)
This notice is also available in alternative formats upon request and at no cost to persons with disabilities.
Para asistencia en español, llame al número de servicio al cliente (customer service) que aparece en el reverso de su tarjeta para miembros.
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What we do
How does Renaissance Life & HealthInsurance Company of America protectmy personal information?
How does Renaissance Life & HealthInsurance Company of America collectmy personal information?
Why can’t I limit all sharing?
To protect your personal information from unauthorized accessand use, we use security measures that comply with federal law.These measures include computer safeguards and secured filesand buildings.
We collect your personal information, for example, when you
Apply for insurance or Pay insurance claimsFile an insurance claim or Use your credit or debit cardGive us your contact information
Federal law gives you the right to limit only
sharing for affiliates’ everyday business purposes–informationabout your creditworthiness
affiliates from using your information to market to you sharing for nonaffiliates to market to you
State laws and individual companies may give you additional rightsto limit sharing.
Definitions
Affiliates
Nonaffiliates
Joint marketing
Companies related by common ownership or control. They can befinancial and nonfinancial companies.
Our affiliates include companies with the Delta Dental name inMichigan, Ohio, Indiana, Kentucky, Tennessee, New Mexico,Arkansas and North Carolina; insurance companies such asRenaissance Life & Health Insurance Company of America andRenaissance Health Insurance Company of New York; and otherssuch as Renaissance Systems & Services, LLC.
Companies not related by common ownership or control. They canbe financial and nonfinancial companies.
Renaissance Life & Health Insurance Company of America doesnot share your personal information with non-affiliates so they canmarket to you.
A formal agreement between nonaffiliated financial companies thattogether market financial products or services to you.
Renaissance Life & Health Insurance Company of America doesnot jointly market with non-affiliated financial companies.
Other important information
For customers in AZ, CA, CT, GA, IL, ME, MA, MN, MT, NV, NJ, NC, OH, OR and VA: To review yourpersonal information, write to Privacy Officer/Legal Department, 4100 Okemos Road, Okemos, MI 48864. Youmust state your full name, address, policy number (if applicable) and the information you would like to see. Wewill tell you what information we have, and you may review and copy it at our office or ask that we mail a copy toyou for a fee. If you think that personal information that we have about you is wrong, you may write to us. Wewill tell you what actions we take because of your letter. If you do not agree with our actions, you may send usa statement.
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